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Winter 12-17-2021

Improving an Electrocardiogram Competency Assessment Tool

for Registered Nurses
Laurel K. Ng
University of San Francisco, [email protected]

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Ng, Laurel K., "Improving an Electrocardiogram Competency Assessment Tool for Registered Nurses"
(2021). Master's Projects and Capstones. 1265.
https://repository.usfca.edu/capstone/1265

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IMPROVING AN ELECTROCARDIOGRAM ASSESSMENT TOOL 1

Improving an Electrocardiogram Competency Assessment Tool for Registered Nurses

Laurel Ng, BSN, RN

University of San Francisco

NURS 660-K8C: Practicum: Quality Improvement and Outcomes Management

Carla Martin, MSN, RN, CIC, CNL, NEA-BC

November 29, 2021

IMPROVING AN ELECTROCARDIOGRAM ASSESSMENT TOOL 2

TABLE OF CONTENTS

Section I: Title and Abstract

Title ........................................................................................................................ 1

Abstract ..................................................................................................................... 4

Section II: Introduction ...................................................................................................... 5

Problem Description ................................................................................................. 6

Available Knowledge ................................................................................................ 7

PICOT Question ............................................................................................ 7

Literature Review .......................................................................................... 7

Rationale ................................................................................................................... 9

Specific Project Aim ................................................................................................. 11

Section III: Methods

Context ...................................................................................................................... 11

Microsystem Assessment .............................................................................. 11

Intervention ............................................................................................................... 13

Study of the Intervention .......................................................................................... 15

Measures ................................................................................................................... 16

Analysis ..................................................................................................................... 16

Ethical Considerations .............................................................................................. 17

Section IV: Results .............................................................................................................. 17

Section V: Discussion

Summary ................................................................................................................... 18

Conclusions ............................................................................................................... 19
IMPROVING AN ELECTROCARDIOGRAM ASSESSMENT TOOL 3

Section VI: References ........................................................................................................ 20

Appendix A. First-Time Pass Rates Pre- and Post-Optimization of Revised EKG

Study Guide ........................................................................................................................ 22

Appendix B. Evaluation Table .............................................................................................. 23

Appendix C. New-Hire Email Sample .................................................................................. 26

Appendix D. Test Question Bank Review by Critical Care and Med/Surg RNs ................. 27

Appendix E. Sample Post-Exam Participant Survey Letter .................................................. 29

Appendix F. EKG Assessment Post-Participant Survey Results ........................................... 30

Appendix G. Statement of Non-Research Determination ..................................................... 33

Appendix H. Post-Implementation of Study Guide Addendum Exam Results ..................... 36

Appendix I. Driver Diagram ................................................................................................. 37

Appendix J. Test Question Data from HealthStream for Period 4/1/2021 – 7/25/2021 ........ 38

Appendix K. SWOT Analysis ............................................................................................... 42

Appendix L. Project Charter ................................................................................................. 43

IMPROVING AN ELECTROCARDIOGRAM ASSESSMENT TOOL 4

Abstract

Problem: Rapid and accurate interpretation of an EKG rhythm is an advanced-level competency

required for all acute care nurses working in a cardiac monitored/telemetry unit. Observational

data collected over a 4-month period by the facility clinical nurse educators identified that less

than half of the nurses required to take the EKG exam passed on the first attempt.

Context: The education department at the facility onboards approximately 550-600 nurses

annually for the 241-bed community hospital in the San Francisco Bay Area of Northern

California, part of a larger healthcare organization.

Interventions: A total of 19 nurses from various departments across the facility were recruited to

evaluate the current EKG assessment tool. Participants ranked the EKG exam questions on a 1-3

Likert scale based on their perceived level of difficulty. The information was collated and used to

create an addendum to the study guide.

Measures: Improve first-time pass rates for the EKG exam in newly-hired nurses at the time of

onboarding by 25%.

Results: The study guide was revised with implementation beginning the week of October 23,

2021. Of the 15 new nurses onboarded since implementation, first-time pass rate improvement

was not demonstrated.

Conclusions: As educators, there is a need to build competencies within a framework that

recognizes the continuum of knowledge ranging from novice to expert and what the appropriate

minimum competency is for nurses to practice safely and within their scope and at every level.

Keywords: EKG, competence, competency assessment, telemetry, onboarding

IMPROVING AN ELECTROCARDIOGRAM ASSESSMENT TOOL 5

Section II: Introduction

According to the American Association of Colleges of Nursing (AACN, 2021), one of

the major challenges in this current environment of value-driven healthcare delivery is ensuring

competent nursing staff to care for patients. Competency is defined as an individual’s ability to

use their knowledge and skills to perform one or more tasks (Miller et al.,1998). Professional

competency in nursing refers to the delivery of nursing care based on professional standards and

is defined as a combination of skills, attitudes, knowledge, values, and abilities that result in

effective performance (Heydari et al., 2016).

Nursing practice is becoming more complex due to patients living longer with chronic

health conditions and who are more critically ill. High-risk cardiac patients previously cared for

in an intensive care unit (ICU) setting until stabilized are now being directly admitted to a lower

acuity setting, such as a telemetry unit. Nonetheless, these patients continue to require close

monitoring and observation for signs of clinical deterioration, which requires advanced skills on

the part of caregivers to ensure optimal outcomes. One such advanced-level competency required

by nurses working in a cardiac monitored/telemetry unit is the ability to rapidly and accurately

identify a life-threatening arrythmia detected by electrocardiogram (EKG) tracings.

Interpretation of an EKG rhythm is complex and clinically challenging. According to Breen et al.

(2019), up to 33% of EKG interpretations have some error, and up to 11 % have resulted in

clinical mismanagement.

Education departments across the organization struggle with consistency and accuracy in

identifying the minimum competencies required for a telemetry nurse to practice safely. This

recognized inconsistency has driven a renewed focus and leadership objective to identify a

specific EKG assessment exam more specific with broad-based applicability across the entire
IMPROVING AN ELECTROCARDIOGRAM ASSESSMENT TOOL 6

Northern California hospital education departments, fulfilling the need for consistent and

accurate assessment of registered nurses (RNs) working in cardiac monitored units at the time of

onboarding. Additionally, the revised instrument must also ensure fair and equitable assessment

of all levels of skill and diversity within nursing across the organization.

Problem Description

Ensuring minimum competency of the nurse is essential in the safe delivery of care.

Misinterpretation of an EKG has the potential to result in poor outcomes, including death.

The standard EKG equipment utilized on most telemetry units includes a telemetry box, which

may have either three or five lead wires, which are then connected to the patient’s anterior chest

wall with adhesive EKG electrodes. More complex interpretation requires a 12-lead EKG tracing

be performed and interpreted by a physician.

RNs working on a telemetry/cardiac monitor unit at the facility are required to take an

EKG assessment exam during orientation to determine competency in caring for monitored

patients. At the time of hire, the hospital provides nurses access to an online EKG study guide to

help new orientees prepare to take the assessment exam. Both the exam and study guide were

developed in 2017 and are used by most of the organization’s Northern California affiliated

hospitals. The exam is accessed electronically via the hospital’s computerized learning platform.

A gap analysis performed by the clinical educators at this facility identified a consistent

pattern of low first-time pass rates in new hires taking the EKG exam at the time of onboarding.

Baseline observational data gathered over a 4-month period, from April 1, 2021, through July 1,

2021, revealed an average first-time pass rate for all nurses at 49% on the didactic portion of the

exam (Part 1) and a dismal 22% first-time pass rate for the rhythm interpretation portion of the

exam (Part 2). Part 2 of the exam requires recognition of both lethal (49%) and non-lethal
IMPROVING AN ELECTROCARDIOGRAM ASSESSMENT TOOL 7

cardiac rhythms (78%). Further analysis of the data identified that approximately 60%-75% of

new hires have medical-surgical level training. First-time pass rates in this group are only 43%,

compared to 50% first-time pass rates in nurses with critical care training and experience (see

Appendix A). This information raises serious concerns about the current testing instrument and

evaluation methods. Therefore, revising the current assessment processes and tools is the focus

of this evidenced-based process improvement initiative.

Available Knowledge

PICOT Question

Melnyk et al.’s (2017) intervention template was used to develop a population,

intervention, comparison, outcome, and time (PICOT) question for this change-of-practice

project. In registered nurses (P), how does a revised EKG assessment tool and study guide (I),

compared to current EKG education (C), affect first-time pass rates over a 3-month period (T)?

Literature Review

A literature search was conducted in the CINAHL database using the terms “EKG OR

electrocardiography” and continuing nurs* education OR professional nurs* development. This

searched revealed nine results, three of which were chosen based on the education methods used

in the studies. Scarcity of data on this topic made it challenging to find literature specific to an

actual exam or assessment instrument to aid nurses in EKG interpretation. The inclusion criteria

included full-text articles published in English within the last 10 years, from 2011 to 2021;

however, one article written in 1998 was included as it provided appropriate evidence to support

this project. Exclusion criteria included book chapters and articles outside the scope of the

project. The Johns Hopkins Evidenced-Based Practice tool was used for the level and quality

rating of each of the chosen articles (see Appendix B).

IMPROVING AN ELECTROCARDIOGRAM ASSESSMENT TOOL 8

In a quality improvement (QI) project utilizing a competency assessment tool based on

literature review, Miller et al. (1998) identified key components in evaluating competency,

which include technical, interpersonal, and critical thinking aspects. Additionally, Miller et al.

discussed the relevancy associated with specific competency behaviors as a nurse moves from

novice to expert. This article is rated as level V-B. Similarly, in another study utilizing a cross-

sectional survey design, Heydari et al. (2016) noted the importance of competency assessment

evaluation. The findings emphasize that nursing competence level directly influences patient

safety. This study is rated as a level III-A. This study is important to this project because of the

need to reflect minimum competency as a safe practitioner. Competencies are also verified by

regulatory agencies.

In a literature review and consensus guideline (rated level IV-A), Breen et al. (2019)

described the interpretation of EKG recordings as complex and clinically challenging and noted

that misinterpretation leads to possible poor patient outcomes or even death. The researchers

concluded that there is no one method for teaching EKG interpretation that suits the needs of all

healthcare professionals

A literature review by Fent et al. (2014), rated as a level V-B, and a randomized study by

Mahler et al. (2011), rated as a level III-A, analyzed medical students in evaluating various EKG

education methodologies utilizing three teaching formats: workshop, lecture, or self-directed

learning. They also reference a study evaluating web-based EKG education. Both studies

concluded that in-person education was more effective than self-directed learning. This has

important ramification for this project, as nurses are expected to engage in self-directed review

of an electronic study guide prior to taking the EKG assessment exam.

IMPROVING AN ELECTROCARDIOGRAM ASSESSMENT TOOL 9

In summary, all studies included utilized some method of educational intervention,

ranging from traditional in-person classroom to e-learning to a hybrid model of both, with the

goal of providing education on interpretation of EKGs. Use of a pre- and post-test when some

form of instruction had been given resulted in an improvement of scores, as opposed to

participants who took the exam with no instruction. The study findings concluded that a hybrid

model (both online and in-person instruction) was the most successful and cost-effective

approach to educating healthcare professionals, compared to solely in-person instruction.

Rationale

For this improvement project, two conceptual frameworks were used to guide this

process improvement initiative. Rogers’ (1983) change theory and Benner’s (1982) novice to

expert model were selected to guide planning and implementation. Rogers’ theory of change

describes five phases that individuals or groups encounter during any change process that

includes learning a new skill. The five phases include awareness, interest, evaluation, trial, and

adoption (Mitchell, 2013).

In the diffusion of innovation theory, Rogers (1983) provides context to the processes

that occur as people adopt a new idea, product, or philosophy. Initially, a few are open to the

idea, and over time, the idea becomes diffused within the population until a saturation point is

achieved (Rogers, 1983). Similarly, at the start of the project, there was support and interest in

the idea as there was awareness of a need for improvement of the exam and study guide.

However, as the project progressed, attentions were diverted to deal with the third wave of the

Delta variant in an ongoing pandemic. Amidst the increasing COVID cases, staffing needs

became more acute, as nursing staff were frequently calling in sick. Since the start of the

pandemic, many had already chosen to leave the field of nursing all altogether, leaving little
IMPROVING AN ELECTROCARDIOGRAM ASSESSMENT TOOL 10

reserve staff. This shortage drove the need to increase staffing, which in turn created the need to

hire and onboard staff rapidly. These external forces only exacerbated the failure rate for new

staff being onboarded. This reality created an even greater sense of urgency in making change at

both the local and regional levels of the organization.

Nurses come into the organization with diverse clinical backgrounds, years of experience,

and different races and ethnicities. According to Benner (1982), the complexity of nursing

practice today requires ongoing and long-term career development. This involves understanding

the differences between the novice nurse and the more experienced nurse, as well as considering

the cultural diversity that exists in nursing. Benner found that the Dreyfus model of skill

acquisition could be applied to nursing, because it considers increments in skill based on

experience, as well as on education. Because the newly-hired nurses have differing levels of

expertise, both experience and education should be accounted for in designing the study guide

and exam. The novice to expert model includes five levels of proficiency: novice, advanced

beginner, competent, proficient, and expert. A nurse develops knowledge, skill, clinical

competence, and comprehension of patient care as they progress in their career (Benner, 1982).

One of the current realities in the training and education of nurses during training

programs is little practical training and application in basic review and interpretation of EKGs.

Therefore, since 60% to 75% of the nurses hired have only medical-surgical nursing experience,

the plan is to create an exam that is consistent with the knowledge, skills, and abilities of a

competent medical-surgical nurse and is suitable for more expert critical care nurses, as well. By

creating a revised EKG study guide and associated exam, the goal is to achieve improved first-

time pass rates in new hires at the time of onboarding.

IMPROVING AN ELECTROCARDIOGRAM ASSESSMENT TOOL 11

Specific Project Aim

The QI project aim is to increase the first-time exam pass rates for newly-hired telemetry

nurses from 92% to 95 % on Part 1 and from 73% to 80% on Part 2 within 3 months post-

implementation of a newly-revised EKG assessment tool and guide for all telemetry nurses

across 21 Northern California in-network hospitals by June 2022.

Section III: Methods

Context

The microsystem selected for this project is the clinical education department, which

serves a 241-bed community hospital within a regional integrated healthcare delivery system

comprising 21 medical centers in Northern California. After completing a microsystem

assessment, a gap in first-time pass rates for nurses taking the EKG competency exam was

discovered.

Microsystem Assessment

The purpose of the clinical education department is to ensure that nurses are competent

and safe to practice because they are caring for the patients that we serve. The professionals in

this microsystem consist of five full-time educators with over 109 cumulative years of

experience. The standard pattern of hospital orientation occurs every 2 weeks on Tuesday. The

orientation processes include sending out an email welcoming the new employees, making them

aware that they will be taking an EKG assessment during the day of orientation, and instructions

for them to review the attached study guide (see Appendix C). It is not mandatory that the new

employee review the study guide prior to orientation. The study guide is an important adjunct, as

it contains the review materials needed for nurses to complete the telemetry exam successfully

on the first attempt. This is important, as low first-time pass rates can affect nurse clinical
IMPROVING AN ELECTROCARDIOGRAM ASSESSMENT TOOL 12

confidence, lack of competence, cost, and coordination of scheduling and unit operations. Nurse

confidence is affected when, despite adequate preparation, the first and/or second attempt is

unsuccessful, and they are required to retake the exam on another day. There is an inordinate

amount of pressure for the employee to pass the exam, as the nurse is not allowed to care for

monitored patients until they have passed and demonstrated competence. Not passing after the

fourth attempt can result in termination because they have not demonstrated competence, unless

the employee is willing to work on a non-telemetry unit, of which there is only one in our

facility.

From a business and operational lens, increased failure rates require the nurse to retake

the exam, which impacts staffing by creating a delay and additional cost to the organization

when unit orientation and placement on the operational schedule are delayed. For every nurse

who fails the telemetry exam, at least one other nurse must pick up that shift, resulting in

significant overtime, which is even more so when there are multiple nurses picking up additional

shifts. The average salary of an RN within the system is $80/hour. A standard 8-hour shift pays

$640. If overtime is incurred, it starts at time and one-half, which adds $120 an hour. After 12

hours, the rate goes to double-time, at $160/hour. If the nurse works an extra 4 hours (a 12-hour

shift), it costs the organization an additional $480, for a total of $1,120. If that nurse works a 16-

hour shift, the additional $640 adds up to $1,760 for the shift.

Educator time and resources are a premium in any organization. Because the exam is

proctored, additional clinical education resources are required for all retests, which must be

rescheduled within a week of the first failed exam. This requires coordination of the employee

and educator, creating additional challenges, with further delays possible. Additional costs are

incurred when the educator must carve out additional hours needed for remediation. Soft and
IMPROVING AN ELECTROCARDIOGRAM ASSESSMENT TOOL 13

indirect costs include the additional technology time, space, and coordinating traveler backfill

(could be as high as $150/hour) until the RN passes the exam, is released to the unit, and is

counted into staffing. There is also the additional cost of re-posting and recruiting, if the

candidate is unsuccessful.

Other factors that cannot be measured are the burnout and stress created within the

existing workforce when the new hire is unable to be placed on the schedule because they failed

to pass the telemetry exam, which in turn can exacerbate shortages in an already overwhelmed

and fatigued staff, increasing sick calls, injury, and error.

Intervention

The plan for this project included a creation and trial of an entirely new study exam

conducted with nurses to determine if the percentage of first-time pass rates increased using the

new exam. Baseline data were collected via a query from the hospital online educational system

for the period of April 1, 2021, to July 1, 2021, to assess and analyze the percentages of first-,

second-, and third-time pass rates with the current exam, as well as the feedback from the

evaluation group. A group of 40 nurses with various backgrounds were selected to participate in

evaluation of the entire bank of test questions from the current exam. A document was emailed

to the participants that included the exam questions (46) in the current test bank, as well as a

request for scoring the level of difficulty on a Likert scale of 1 to 3, their reason for that rating,

and what they would select for the answer to the question based on utilization of the study guide

and their own knowledge base. A total of 38% (n = 15) responses were received—nine from

critical care nurses and six from medical-surgical nurses. Low return rates were attributed to the

COVID-19 pandemic effects on staffing ratios and workload demands. Once the evaluations
IMPROVING AN ELECTROCARDIOGRAM ASSESSMENT TOOL 14

were completed, all questions were put into a table based on their rating (see Appendix D). Any

comments related to the questions were included to further evaluate the rating.

Unfortunately, pandemic-related activities resulted in a reallocation of resources for this

project; therefore, the scope of the project was scaled back to revision of the study guide as the

means to improve first-time pass rates. Using the data from the original PDSA (plan, do, study,

act) completed, an addendum to the study guide was created and added to the email attachment

sent to all new hires as part of the standard onboarding process. The addendum focused on the

two-part exam: the first five questions are lethal rhythms, and the second 20 questions involve

rhythm identification, as well as interventions.

To obtain real-time feedback regarding the study guide addendum from new employees,

a second PDSA cycle was initiated. In this second phase, an evaluation of the current exam

utilizing a five-question survey was sent to each new hire via email post-exam completion during

the week of orientation (see Appendix E). The survey questions included collection of pass/fail

data on the first attempt, if the study guide was reviewed prior to testing, and what specifically

did they find difficult about the exam, e.g., wording of questions or which rhythms were

difficult.

The final inquiry was obtaining information on what other learning needs existed and

suggestions to what they would improve about the current exam (rhythm strips, questions,

pacemaker, heart blocks, or other). Additionally, after initiation of a study guide addendum, a

question inquiring if the addendum was reviewed and if it was found to be helpful was added.

The survey results are reflected in Appendix F. Data collection and analysis of test scores post-

implementation of the revised study guide will be used to inform next steps as part of the PDSA
IMPROVING AN ELECTROCARDIOGRAM ASSESSMENT TOOL 15

cycles and will be integrated to evaluate incremental progress (Institute for Healthcare

Improvement [IHI], 2021a).

Study of the Intervention

To measure the effectiveness of the study guide addendum, the five-question survey

mentioned above was implemented on October 23, 2021. In the first group of new hires (n = 12),

there was a low response rate to the survey sent via email. After one week, a follow-up email

was sent to those who had not responded, which resulted in a slightly higher response rate (from

25% to 60%). Since many of the nurses are younger and tend to be digital natives, a QR code

was created that could be scanned on the smart phone and link the participants directly to the

survey. A paper with the QR code is given once the telemetry exam is completed. This

adaptation has proven to be more efficient, resulting in quicker and increased data collection.

Analysis of these data revealed that first-time pass rates, as well as test scores, were higher in

those who responded that they had reviewed the study guide. Using this information, the email

letter sent to new hires was revised, emphasizing the need to review the study guide and

addendum thoroughly prior to the exam.

Having to pivot in the wake of the Delta surge limited time for the project, thus creating

the addendum to the study guide, which includes creating a review of the heart blocks rather than

revising the entire study guide. Although early in the process, at this time, it does not appear to

have increased first-time pass rates for both parts of the exam in those who review the study

guide addendum (31% on Part 1 and 7.7% on Part 2).

Future iterations include consideration of additional questions to the QR code survey

post-exam, which includes gathering information on years of experience. Other actionable data

might be obtained that can be used to inform all aspects of clinical education to ensure
IMPROVING AN ELECTROCARDIOGRAM ASSESSMENT TOOL 16

educational curriculum and teaching methods are inclusive and help achieve a more equitable

and consistent exam.

Measures

The primary outcome measure for this project is to increase the first-time pass rates for

newly-hired telemetry nurses from 92% to 98% on Part 1 of the exam and from 73% to 80% on

Part 2 of the exam within 3 months post-introduction of a newly-revised EKG assessment tool

and study guide. The first process measure is the creation and distribution of the evaluation

document for the current exam bank of questions. The second process measure is to analyze the

number of questions that the participants rated as the most difficult, from 1 to 3 on the Likert

scale. This will improve the clarity of things related to the questions and what revisions may be

necessary. The third process measure will be revision of the study guide. The balancing measure

is the need to reschedule the proctored exam with a clinical educator.

The measures of this improvement project will be evaluated by compiling data via a

report on Part 1 and Part 2 of the exam via the hospital online education platform. A

retrospective data collection was done for the 4-month period described earlier, and current data

are being collected every 2 weeks concurrent with the bi-monthly patient care services

orientation, in which the exam is given.

Analysis

Due to limited time, analysis of the project is currently ongoing; however, since

implementation with three orientation groups, the first-time pass rates did not improve at all.

More time is needed to determine the effectiveness of the revised study guide, as well as any

other additional changes that can be made after more input from the post-test survey has been

collected and evaluated.

IMPROVING AN ELECTROCARDIOGRAM ASSESSMENT TOOL 17

Ethical Considerations

Clinical educators need to build competencies within a framework that recognizes the

continuum of knowledge ranging from novice to expert and what the appropriate minimum

competency is for nurses to practice safely, within their scope, and at every level. Justice is the

ethical principal that must guide education of the nursing workforce. The principle of justice

demands fairness with equal access to resources related to learning and educating others,

recognizing the ethnic and racial diversity that exists in healthcare professionals today and

ensuring our processes are just and serve all and not just a select few. The nursing staff at the

facility includes nurses from all cultures and backgrounds, such as Filipino, Indian, Hispanic,

Caucasian, and Asian. Therefore, as educators, it is important to tailor education in a way that

recognizes this diversity by incorporating tests and other assessment tools that are equitable and

accessible, so that one group is not disproportionally affected over the other.

In addition to justice, the ethical principles of beneficence (moral obligation to do the

right thing) and non-maleficence (avoiding causation of harm) are applicable to this project. It is

crucial that new-hire telemetry nurse competency be established and evaluated prior to caring for

any monitored patient, thus promoting patient safety.

This project has been approved as a QI project by faculty using QI review guidelines and

does not require IRB approval (see Appendix G).

Section IV: Results

This project was forced to pivot more than once, creating time constraints and preventing

a complete analysis of the impact of the newly-created study guide addendum on first-time pass

rates. The small sample of participants who gave feedback indicated that the addendum was

helpful; although, a true improvement in scores related to the addendum was not identified.
IMPROVING AN ELECTROCARDIOGRAM ASSESSMENT TOOL 18

Thirteen participants took the exam after the addendum was added (two ICU RNs and 11

med/surg RNs). The email letter was revised to emphasize the need to thoroughly review the

study guide and addendum. The results on Part 1 of the exam were 31% (four of 13) passed the

first time, seven passed the second time, and two took three or more attempts to pass. On Part 2

of the exam, out of 13 participants, only one passed the first time (7.69%), six passed the second

time, and six took three or more attempts to pass. Test results evaluated after initiation of the

addendum to the study guide demonstrated that it was not effective in improving first-time pass

rates (see Appendix H).

Section V: Discussion

Summary

Learning is complex, and in the wake of a pandemic, where stress and burnout are

becoming the norm, finding new ways to assess minimum competency in new staff is an

imperative. The literature suggests that there is no one way that works for everyone. While there

was some limited improvement in first-time pass rates for those who used the study guide

addendum, it was a minority group. Staff are willing to engage in other modalities for learning

that integrate technology into the mix, as evidenced by increased participation with the survey

when a QR code and smart phone were integrated. Perhaps, using a classroom testing model,

where students answer individual test questions and identify rhythms on their smart phone, may

be an effective method. Their response is recorded in real-time, providing immediate feedback to

the educator when students are struggling with a concept or question. Nurses must remain

engaged learners, and educators must explore new ways to engage a younger and more

technologically savvy workforce. Given the results and findings of this limited study, perhaps it
IMPROVING AN ELECTROCARDIOGRAM ASSESSMENT TOOL 19

is not the test or the study guide that needs to be updated, but instead the entire educational

delivery model.

Conclusions

The clinical nurse leader (CNL) is ideally prepared as an educator and outcomes manager

to lead system-based practice change projects (Bender et al., 2019). This author, a CNL student

and clinical nurse educator, led a QI project to introduce a new approach to improve the

competency-based telemetry assessment tool for all newly-hired nurses assigned to monitored

units. As educators, there is a need to build competencies within a framework that recognizes the

continuum of knowledge ranging from novice to expert and what the appropriate minimum

competency is for nurses to practice safely and within their scope. Furthermore, as diversity in

healthcare increases, there is a need to ensure that educational competencies reflect the changes

of the current workforce. Therefore, organizational priorities must include ongoing education

and training to ensure nurse competencies are on plane with the diversity of the labor force, as

well as patient acuity.

This project began as an attempt to improve the first-time pass rates of the current EKG

assessment by reviewing the current exam and study guide, with plans to revise both after several

PDSA cycles; however, what was learned is the current educational delivery models may no

longer have utility in assessing the competency of the workforce of the future.
IMPROVING AN ELECTROCARDIOGRAM ASSESSMENT TOOL 20

Section VI: References

American Association of Colleges of Nursing (2021). The essentials: Core competencies for

professional nursing education.

https://www.aacnnursing.org/Portals/42/AcademicNursing/pdf/Essentials-2021.pdf

Bender, M., Baker, P., Harris, J. L., Hites, L., LaPointe, R., Murphy, L., Roussel, L., Spiva, L.,

Stanley, J., Thomas, T., & Williams, M. (2019). Advancing the clinical nurse leader

model through academic-practice-policy partnership. Nursing Outlook, 67(4), 345–353.

https://doi.org/10.1016/j.outlook.2019.02.007

Benner, P. (1982). From novice to expert. American Journal of Nursing, 82(3), 402–407.

https://journals.lww.com/ajnonline/Citation/1982/82030/From_Novice_To_Expert.4.aspx

Breen, C. J., Kelly, G. P., & Kernohan, W. G. (2019). EKG interpretation skill acquisition: A

review of learning, teaching, and assessment. Journal of Electrocardiology. Online

publication. https://doi.org/10.1016/j.jelectrocard.2019.03.010

Fent, G., Gosai, J., & Purva, M. (2014). Teaching the interpretation of electrocardiograms:

Which method is best? Journal of Electrocardiology, 48(2), 190–193.

https://doi.org/10.1016/j.jelectrocard.2014.12.014

Francis, J. (2016). ECG monitoring leads and special leads. Indian Pacing and Electrophysiology

Journal, 16(3), 92–95. https://dx.doi.org/10.1016/j.ipej.2016.07.003

Garland, A., & Connors, A. F. (2013). Optimal timing of transfer out of the intensive care unit.

American Journal of Critical Care, 22(5). https://doi.org/10.4037/ajcc2013973

Heydari, A., Kareshki, H., & Armat, M. R. (2016). Is nurses’ professional competence related to

their personality and emotional intelligence? A cross-sectional study. Journal of Caring

Science, 5(2),121–132. https://doi.org/10.15171/jcs.2016.013

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Institute for Healthcare Improvement. (2021a). Plan-do-study-act (PDSA) worksheet.

Ihi.org/resources/Pages/Tools/PlanDoStudyActWorksheet.aspx

Institute For Healthcare Improvement. (2021b). Science of improvement: Testing changes.

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es.aspx

Mahler, S. A., Wolcott, C. J., Swoboda, T. K., Wang, H., & Arnold, T. C. (2011). Techniques for

teaching electrocardiogram interpretation: Self-directed learning is less effective. Medical

Education, 45(4), 347–353. https://doi.org/10.1111/j.1365-2923.2010.03891.x

Melnyk, B. M., Gallagher-Ford, L., & Fineout-Overholt, E. (2017). Implementing evidence-

based practice competencies in healthcare. Sigma Theta Tau International.

Miller, E., Flynn, J. M., & Umadac, J. (1998). Assessing, developing, and maintaining staff’s

competency in times of restructuring. Journal of Nursing Care Quality, 12(6), 9–17.

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Mitchell, G. (2013). Selecting the best theory to implement planned change. Nursing

Management, 20(1), 32–37. https://doi.org/10.7748/nm2013.04.20.1.32.e1013

Rogers, E. (1983). Diffusions of innovations (3rd ed.). Free Press.

IMPROVING AN ELECTROCARDIOGRAM ASSESSMENT TOOL 22
Appendix A
First-Time Pass Rates Pre- and Post-Optimization of Revised EKG Study Guide
IMPROVING AN ELECTROCARDIOGRAM ASSESSMENT TOOL 23

Appendix B

Evaluation Table

Evidence
Study Design Sample Outcome/Feasibility
Rating
Bender, M., Baker, P., Harris, J. L., Clinical Three taskforces were The CNL is a nursing education and practice initiative IV A
Hites, L., LaPointe, R., Murphy, L., practice created for different that has expanded and grown over 18 years. The CNL
Roussel, L., Spiva, L., Stanley, J., guidelines aspects of the initiative was created to allow nurses, educated and
Thomas, T., & Williams, M. (2019). program, with organized into models of care, to effectively improve
Advancing the clinical nurse leader Consensus multiple PDSA quality and safety. The CNLRC will continue to
model through academic-practice- panels processes completed expand the CNL role.
policy partnership. Nursing Outlook, as the program grew.
67(4), 345–353.
https://doi.org/10.1016/j.outlook.2019
.02.007
Breen, C. J., Kelly, G. P., & Consensus Review of multiple There remain no established standard teaching IV A
Kernohan, W. G. (2019). EKG guideline studies/articles (32). methods for EKG interpretation that are evidenced-
interpretation skill acquisition: A based. There are a number of areas for future
review of learning, teaching, and development within EKG acquisition and
assessment. Journal of interpretation. Integration of a multi-modal approach
Electrocardiology. Online is necessary, as well as training, testing, and re-
publication. testing.
https://doi.org/10.1016/j.jelectrocard.
2019.03.010
Fent, G., Gosai, J., & Purva, M. Literature Critical evaluation of Summary of teaching methods, including SDL (self- VB
(2014). Teaching the interpretation of review multiple teaching directed learning), workshop-based teaching, lecture-
electrocardiograms: Which method is formats. based teaching, web-based learning, user-generated
best? Journal of Electrocardiology, video learning, contrastive teaching method, & non-
48(2), 190–193. contrastive teaching method. Conclusion was that
https://doi.org/10.1016/j.jelectrocard. there is no standard method for EKG interpretation
2014.12.014 that is applied uniformly. Also discussed was that
many of the studies reviewed shared a common flaw
in that they did not utilize a “retention” test in addition
to a pre- and post-test.
IMPROVING AN ELECTROCARDIOGRAM ASSESSMENT TOOL 24

Francis, J. (2016). ECG monitoring Case reports Evaluation of 11 Discusses the more commonly used lead placement VA
leads and special leads. Indian Pacing different EKG lead for standard monitoring, but also presents specialty
and Electrophysiology Journal, 16(3), placement methods situations in which different lead placement will
92–95. for varied patient provide improved monitoring.
https://dx.doi.org/10.1016/j.ipej.2016. needs.
07.003
Garland, A., & Connors, A. F. (2013). Prospective, 2,041 ICU survivors Overall, 30-day mortality was 10.1%. Mean IB
Optimal timing of transfer out of the observational in a 13-bed, closed- discharge delay was 9.6 hours, 9.9% has a discharge
intensive care unit. American Journal cohort study model, adult ICU in a delay over 24 hours. The relationship of 30-day
of Critical Care, 22(5). county-owned, mortality to discharge delay was statistically
https://doi.org/10.4037/ajcc2013973 university-affiliated significant and U-shaped, with the nadir at 20 hours.
hospital. Logistic The data indicated an optimal time window for
regression was used patients to leave the ICU, with increased mortality,
to assess the both when they leave earlier and when they are
association of delay delayed and leave later than the optimal timing.
of discharge with 30-
day mortality.
Heydari, A., Kareshki, H., & Armat, Cross-sectional 220 Iranian BSN Overall, Iranian clinical nurses rated their professional III A
M. R. (2016). Is nurses’ professional survey level RNs, competencies as “good” and “very good.” Included in
competence related to their 3 instruments were this evaluation was the nurse’s competence level and
personality and emotional used:1. Nurse its association with their personality traits and
intelligence? A cross-sectional study. Competence Scale; 2. emotional intelligence. This allowed nursing leaders
Journal of Caring Science, 5(2),121– Schutte Self Report to consider all these components in developing high-
132. Emotional functioning teams. However, further studies are
https://doi.org/10.15171/jcs.2016.013 Intelligence Test; 3. needed, and systematic and regular evaluation is
Big Five Factor necessary.
Inventory.
Mahler, S. A., Wolcott, C. J., Randomized 223 4th-year medical All 3 teaching formats resulted in a statistically III A
Swoboda, T. K., Wang, H., & Arnold, study students studied over significant improvement in individual test scores (p <
T. C. (2011). Techniques for teaching a 28-month period; 3 0.001). Comparison of the lecture and workshop-
electrocardiogram interpretation: teaching formats based formats demonstrated no difference is test
Self-directed learning is less effective. utilized with a pre- scores; self-directed learning scores were lower than
Medical Education, 45(4), 347–353. test, post-test, and a the other two groups.
https://doi.org/10.1111/j.1365- retention test given.
2923.2010.03891.x
IMPROVING AN ELECTROCARDIOGRAM ASSESSMENT TOOL 25

Miller, E., Flynn, J. M., & Umadac, J. Literature 1st pilot: 33 RNs and Competency was improved after education was VB
(1998). Assessing, developing, and review 9 LPNs; assessment completed. This was true even at the 3-month point.
maintaining staff’s competency in tool using a 5-point LOS was reduced in specialty units after education
times of restructuring. Journal of QI project Likert scale. was completed (SICU - 16%), as well as the M/S unit
Nursing Care Quality, 12(6), 9–17. 2nd pilot: 36 RNs, (47%).
https://doi.org/10.1097/00001786- focus on neuro- Carefully designed competency assessment tools were
199808000-00005 assessment successful in developing effective educational
education; 10- programs that can be maintained for staff, even during
question multiple- a restructuring process where new skills can be
choice assessment learned and utilized to provide safe patient care.
tool pre- and post-
course, & 3-mos
after.
Both used classroom
instruction, case
studies, and hands-on
practice.
Mitchell, G. (2013). Selecting the best Literature Review and VA
theory to implement planned change. review comparison of
Nursing Management, 20(1), 32–37. multiple change
https://doi.org/10.7748/nm2013.04.20 theories (Lippitt,
.1.32.e1013 Lewin, Rogers).
IMPROVING AN ELECTROCARDIOGRAM ASSESSMENT TOOL 26

Appendix C

New-Hire Email Sample

QR Code for EKG QR Code for EKG

Study Guide Study Guide Addendum

IMPROVING AN ELECTROCARDIOGRAM ASSESSMENT TOOL 27

Appendix D

Test Question Bank Review by Critical Care and Med/Surg RNs

IMPROVING AN ELECTROCARDIOGRAM ASSESSMENT TOOL 28
IMPROVING AN ELECTROCARDIOGRAM ASSESSMENT TOOL 29

Appendix E

Sample Post-Exam Participant Survey Letter

Hi All,
It was nice meeting you all yesterday for orientation.
I had mentioned asking for your feedback on the exam and study guide as part of my
MSN final project.
If you can answer the following questions for me, I would be greatly appreciative.

1. Did you use the study guide?

2. Did you pass the first time?
3. What did you find difficult about the exam?
4. Which rhythms were difficult?
5. What would you improve about the study guide or exam (rhythm strips,
questions, etc.)
6. Did you review the addendum to the study guide and did you find it
helpful? (Added after addendum to study guide was introduced).

Thanks in advance for your feedback!

Sincerely,
Laurel Ng

Laurel K. Ng, BSN, RN, CNOR

Perioperative Clinical Educator
Kaiser Walnut Creek
1425 S. Main St.
Walnut Creek, CA 94596
Cell: 925-393-3840
Office: 925-295-5270
IMPROVING AN ELECTROCARDIOGRAM ASSESSMENT TOOL 30

Appendix F

EKG Assessment Post-Participant Survey Results

Questions:

1. Did you use the study guide?

2. Did you pass on the first attempt?
3. What was difficult about the exam?
4. Which rhythms were the most difficult?
5. What would you improve? (rhythm strips, questions, pacemaker questions, block
questions, etc.)
6. Did you review the addendum to the study guide and was it helpful? (Added after addendum
created)

Of note: Out of 19 participant surveys, only 12 responses were received.

PARTICIPANT QUESTION RESPONSE

1 1 Y
2 N
3 Heart blocks
4 Heart blocks
5 An easier way to understand heart blocks

2 1 Y
2 Y
3 Some of the strips were difficult to count the blocks- the
ones where the 1 second divisions were not clear and bold
4 I had a little trouble with junctional and idioventricular
rhythms
5 Image quality of some of the strips

3 1 Y
2 N
3 Pacemakers, Heart blocks
4 Pacemakers, Heart blocks
5 Content of study guide is overwhelming for a med-surg
nurse. Maybe have a “notes” or “tips” section to help nurses
remember the blocks easier

4 1 Y- I used some of it
2 Y
3 Some content seems too in depth for the average tele nurse-
more geared to the critical care nurse
4 A-fib and Idioventricular. There were two rhythms that read
a-fib and a-flutter and the study guide had those rhythms
identified as opposite or what the test said was correct
IMPROVING AN ELECTROCARDIOGRAM ASSESSMENT TOOL 31

5 Improve the electrical system questions. No one needs to

know that the AV rate is 20-40. It’s not that important.
What is more important is knowing every rhythm. And
don’t use the same strip for different rhythms (ie, a-fib/a-
flutter). Make sure the study guide matches the test. Maybe
add more examples of the strips in the study guide to help
the average tele nurse who doesn’t have as much experience

5 1 Y
2 N
3 Blocks and pacemakers
4 Same as above
5 Study guide helpful but a little overwhelming. On one of
the questions, the study guide and exam contradict each
other (a-fib/a-flutter)

6 1 Y
2 Y
3 Strips had different looks including color of strip and size
4 For the most part it was ok but having a standard look for
the strips would have been nice
5 The study guide was great with lots of helpful information.
A standard approach to the strips is all I would change

7 1 N
2 N
3 I found it hard not passing the first time
4 I found the blocks difficult
5 I would make it more direct, instead of having to infer the
information and applying it

8 1 I did not review the whole study guide before the exam
2 N
3 I thought the heart blocks were difficult
4 I had trouble w the heart blocks
5 After going through the study guide, I found it very
informative

9 1 No, I did not have time to study before. I glossed over it and
it was a nice review
2 Y
3 Trick questions w preparing meds. In ACLS, you will prep
the first line med, which is almost always epi. I think I
chose both epi and then anticipated the use of amiodorone
later. Not difficult, just tricky
IMPROVING AN ELECTROCARDIOGRAM ASSESSMENT TOOL 32

4 Not difficult but hard to decipher. I wished we had the

option to have a caliper and to zoom in or maximize the
screen
5 Please refer to 2 & 3
6 Y

10 1 Y
2 Y
3 Heart blocks challenging. Some strips could be improved
4 Junctional
5 Some questions were not clear based on study guide info
6 Y

11 1 Y
2 N
3 Most were reasonable
4 Idioventricular
5 Study guide was helpful
6 Y

12 1 Y
2 N
3 Strips, heart blocks, idioventricular, PJC’s
4 Idioventricular, blocks, PJC’s
5 Strips
6 Y
IMPROVING AN ELECTROCARDIOGRAM ASSESSMENT TOOL 33

Appendix G

Statement of Non-Research Determination

IMPROVING AN ELECTROCARDIOGRAM ASSESSMENT TOOL 34
IMPROVING AN ELECTROCARDIOGRAM ASSESSMENT TOOL 35
IMPROVING AN ELECTROCARDIOGRAM ASSESSMENT TOOL 36

Appendix H

Post-Implementation of Study Guide Addendum Exam Results

PART 1 Attempts Pass 100 %

Initials Score Specialty
BW 60 -100 MS
EY 80 -100 MS
TS 80 -100 MS
AL 20-40-80-100 MS
MH 60 -100 MS
JC 40 -100 MS
CB 100 MS
GM 60 -80-100 MS
JD 100 MS
DM 100 MS
LJ 80-100 ICU
ML 100 MS
HT 80-100 ICU

PART 2 Pass: 80%

BW 70 -85 MS
EY 55-65-75-90 MS
TS 70-75-80 MS
AL 35-60-65-80 MS
MH 55-80-100 MS
JC 40-80 MS
CB 55-75-80 MS
GM 65-75-100 MS
JD 65-80 MS
DM 70-85 MS
LJ 80 ICU
ML 65-90 MS
HT 70-90 ICU
IMPROVING AN ELECTROCARDIOGRAM ASSESSMENT TOOL 37

Appendix I

Driver Diagram
 IMPROVING AN ELECTROCARDIOGRAM ASSESSMENT TOOL 38

Appendix J

Test Question Data from HealthStream for Period 4/1/2021 – 7/25/2021

QUESTION TOPIC ANSWER TIMES RESPONSES % OF

# PRESENTED STUDENTS
1 Pulseless VT 134
C 116 87

2 Idioventricular 134
C 122 91

3 3rd degree 134

C 118 88

4 VT 134
B 130 97

5 SVT 134
C 119 89

6 PEA 44
D 37 84

7 V-Paced w appropriate capture and 48

sensing
B 31 65

8 VT w pulse 50
A 43 86
D 31 62
E 43 86
Times 22 (44%)
answered
correctly
(TAC)

9 V paced failure to sense 68

A 47 69
TAC 38 (56%)

10 Monitor alarms-interventions 51
B 50 98
C 46 90
TAC 37 (73%)

11 PEA (Code Blue) 67

A 65 97
 IMPROVING AN ELECTROCARDIOGRAM ASSESSMENT TOOL 39

C 57 85
TAC 52 (78%)

12 Pacer failure to capture-interventions 64

D 49 77

13 SVT-treatment 61
D 51 84

14 Bradycardia-tx 48
C 46 96

15 Toursades 55
A 49 89

16 A-Fib-Tx 50
A 41 82
C 41 82
TAC 21 (42%)

17 A-Flutter 48
B 35 72

18 A-fib uncontrolled 60
A 43 72

19 A-Fib 2 62
C 55 89

20 A-Fib 3 68
D 57 84

21 A-Flutter 64
B 56 88

22 2nd degree type II 85

C 71 84

23 3rd degree 79
E 40 51

24 2nd degree type I (Wenkebach) 151

A 87 58

25 Junctional 96
D 69 72

26 1st degree block 84

 IMPROVING AN ELECTROCARDIOGRAM ASSESSMENT TOOL 40

B 68 81

27 Idioventricular 94
D 89 95

28 Junctional-2 88
B 63 72

29 2nd degree type II-a 78

B 41 53

30 Sinus node intrinsic rate 83

C 76 92

31 AV node intrinsic rate 98

B 88 90

32 PR Interval 95
C 72 76
E 88 93

33 Ventricular intrinsic rate 91

C 65 71

34 QRS 86
D 78 91
TAC 30 (35%)

35 PJC 52
B 21 40

36 ST 53
C 36 68

37 SB 63
D 24 38

38 ST-2 75
C 59 79

39 NSR w/ MF PVC 57
D 42 74

40 NSR 65
A 58 89

41 PAC’s 67
B 40 60
 IMPROVING AN ELECTROCARDIOGRAM ASSESSMENT TOOL 41

42 PAC-2 56
A 27 48

43 NSR w/ UF PVC’s 59
A 46 78

44 PVC-Couplet 56
A 28 50

45 SVT 151
C 143 95

46 VF 74
B 69 93

47 VF-2 77
B 70 91
IMPROVING AN ELECTROCARDIOGRAM ASSESSMENT TOOL 42

Appendix K

SWOT Analysis

STRENGTHS WEAKNESSES OPPORTUNITIES THREATS

Extensive study Perhaps too much Find a balance with Failure to pass the
guide with lots of information in study amount if information exam the first time
information guide in study guide causes delays in
onboarding
Online exam allows Exam strips could be Improve both the Process to make
participant to repeat a improved study guide and exam changes can be
second time the same challenging across a
day regional medical
system
Less than optimal Improve first-time Lack of staffing
first-time pass rates pass rates relief because of
delays
Perhaps exam is more
than needed?
IMPROVING AN ELECTROCARDIOGRAM ASSESSMENT TOOL 43
Appendix L

Project Charter

Project Charter: Improving a competency-based electrocardiogram (ECG/EKG) assessment

tool for medical-surgical level new-hire registered nurses.
Global Aim: To introduce a reliable and user-friendly EKG competency tool for assessment in
non-ICU level nursing education across 21 Northern California medical centers within 2 years.
Specific Aim: To increase the first-attempt pass rate for newly-hired, non-ICU trained nurses
from the current exam of 92% to 95% on Part 1 of the exam, and from 73% to 80% on Part 2 of
the exam within 3 months post-implementation of a new EKG competency assessment tool.
Background:
Competency is an assessment of an employee’s ability to perform a skill or task. According to
the American Association of Colleges of Nursing (AACN, 2021), one of the major challenges in
this current environment of value-driven healthcare delivery is ensuring competent nursing staff
to care for patients. Nursing practice is becoming more complex due to patients living longer
with chronic health conditions and more critically ill. This increases the demands and
competencies for nurses to adhere to evidence-based practice while caring for more complex
patients (AACN, 2021).
An example of an advanced level of competency is the rapid and accurate determination of EKG
rhythm interpretation, which can be lifesaving. In a monitored unit, competency in this skill is
crucial. Healthcare organizations need to integrate a reliable, accurate assessment of all nurses
caring for monitored patients to optimize safety and accountability. Utilizing a tool that is fair
and equitable for all levels of nursing practice to determine competency in caring for monitored
patients is essential. According to Breen et al. (2019), “The correct interpretation of 12-lead ECG
recordings is complex and clinically challenging with misinterpretation having the potential to
result in poor outcomes or even patient fatality” (p. 1). The literature demonstrates that up to
33% of ECG interpretations have some error, and up to 11% have resulted in mismanagement
(Breen, et al., 2019).
Sponsors
Regional Professional Development and Education Department
Clinical Practice and Informatics Department
Goals
To create a single reliable exam and study guide for the Northern California region that is fair
and equitable for the medical-surgical level new-hire telemetry nurse.
 IMPROVING AN ELECTROCARDIOGRAM ASSESSMENT TOOL 44
Measures
Measure Data Source Target
Outcome
1. Achieve 90% pass rate on Revised exam 48 newly-hired telemetry RNs
Part 2 of the exam after pilot (non-ICU)
exam
Process
1. Peer consult on exam Current exam and pilot exam 15 nurse educators and
experienced telemetry RN
volunteers
2. Implement pilot test #1 Exam results 8-10 (based on number of
exam takers in 1st pilot test)
Balancing Measure Monitor pass rates during # of people who took it vs pass
Delta Covid surge rates during Aug/Sept/Oct
Evaluation after 2 rounds of Exam results 16-20
new exam
Sustainability plan - work with team to continue to monitor and collect data.
Team
Regional Director of Professional Development and BY
Education
Regional Clinical Practice Consultant and HealthStream CW
Administrator
Clinical Education, Practice and Informatics Department JR, CD, AF, AH, LS

Measurement Strategy
Background (Global Aim): To introduce a reliable and user-friendly EKG competency tool for
assessment in non-ICU level nursing education across 21 Northern California medical centers
within 6 months.
Population Criteria: New-hire RNs on monitored units, specifically the medical-surgical level
nurse, but including the ICU level nurse.
Data Collection Method: Retrospective data collection from the last 4 months of nurses
required to take the EKG assessment to determine the percentages of first, second or third
attempt pass rates; creating a QR code or survey-based evaluation of current exam and follow-up
survey after revision of the exam. Ongoing data collection every 2 weeks, with the
administration of the exam to each new-hire telemetry RN required to take the exam.
IMPROVING AN ELECTROCARDIOGRAM ASSESSMENT TOOL 45
Measure Description
Measure Measure Definition Data Collection Goal
Source
Part 1 pass rate 1st, 2nd, 3rd time HealthStream Report Determine current
pass rates
Part 2 pass rate 1st, 2nd, 3rd, 4th, or HealthStream Report Determine current
5th time pass rates